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HEALTH DISTRICT w- <br /> AN JOAQUIN LOCAL HEAL Calif . Y <br /> - Stockton, <br /> . .� <br /> 1601 E. Hazelton Ave. > gl� <br /> Foy_- OFFGfi6-�67$l <br /> ICE USE: Telephone: (209) PERMIT <br /> APPLICATION FOR WELL. 77'Sp�p .CONSTRUCTION OR PUMP Permit No. <br /> Date issued L-2- <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> I 1 (Complete In Triplicate} permit to construct <br /> Application is 'hereby de 'to the San Joaquin Local Health District far a <br /> y mascribed. This application is .made in uimri L <br /> an <br /> County Ordinance No. 1862n <br /> ocale Heal hSDistrict.t <br /> I and/or install the work herein de <br /> � ad the Rules and Regulations of the San Joaq <br /> 1 �U CENSUS TRACT <br /> k JOB ADD TION ' phone <br /> F ! <br /> Owner's Name City <br /> Address <br /> / License # Phone <br /> ' Contractor's Name <br /> l ; 4 <br /> DESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I IRECONDITION EPAIR / II P REPLACEMENT /� <br /> PUMP INSTALLATION —pump <br /> Other <br /> ' PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES./l7(J OTHER _ <br /> SEWAGE DISPOSAL FIELD -CESSPOOL/SEEPAGE PTT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CO_NSTRUCTI PUBLIC <br /> DOSTIC SPECIFIC WELL ONS <br /> INTENDED USE TYPE OF WELL - - <br /> Industrial X Cable Tool Dia. of Well Excavation /_ <br /> Domestic/private Drilled Dia. of Well Casing -J�� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Gr-out-Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical —Surface__S_eal Installed By: <br /> PUMP INSTALLATION: Ctractor <br /> Type of Pump < H.P. /S;-rz <br /> PUMP REPLACEMENT: . / i/ State .Work Done <br /> 3 w <br /> PUMP .REPAIR: / i/ State Work Done <br /> De � <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> c.n <br /> Describe Material and Procedure ' <br /> I hereby agree to compfy-lwith all laws and regulat- ons of:the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating�wel_l..constriiction. Within FIFTEEN--DAYS <br /> after completion of my work on a new well; I will_furnish vthe San Joaquin Local Healtki. Aistricl <br /> WELL DRILLERS REPORT of the well and no/t3'3':y? ttiem-bef6r6,-piliting' the well in use. The above- ' <br /> information is true to the fest of my:.knowledge and belief. IV WILL CALL FOR A GROUT INSPECTIOr <br /> PRIOR TO GROUT ING AND A FINAL INSPECTIO <br /> SIGNED I TITLE <br /> DRAW.-PL PLAN 'ON RE EkSE SIDE) <br /> FOR DEPARTMENT USE ONLY r� <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: , <br /> .PHASE.-II .GROU.T_..INSPECT. N_._ PHASE II_I/FINAL_INSPEC <br /> ..,_ ION <br /> INSPECTION BY DATE s /�-' �� INSPECTION BY (1 DATE 2- <br /> -- 3/76 2M <br /> E H 1426 Rev. 1-74 -•* <br />